How will access to contraception coverage fare in light of the ACA repeal?

With the uncertainty about continued contraception coverage, a number of states have either enacted or introduced legislation to ensure that individuals continue to have access to contraception coverage and the number of women inquiring about birth control has increased. Since the November election and, in the wake of the imminent repeal of Obamacare, requests for intrauterine devices (IUDs) have been increasing significantly. Cecile Richards, President of Planned Parenthood, told CNN on January 9, 2017, that the demand for IUDs, a form of long-term birth control, has shot up 900 percent at Planned Parenthood branches because women “are desperately concerned that they will lose their access to health care,” SFGate news reported.

A December 7, 2016, Kaiser Family Foundation report that addressed private insurance coverage of contraception stated that many states have mandated minimum benefits for decades, including contraceptive coverage. Moreover, since the passage of the Affordable Care Act (ACA) (P.L. 111-148), states have strengthened and expanded the federal contraceptive coverage requirement. Among those states that have recently adopted contraceptive laws expanding ACA mandates for contraceptive coverage are New York, California, Oregon, Illinois, and Vermont.

New York

On January 11, 2017,  New York Attorney General Eric T. Schneiderman introduced “The Comprehensive Contraception Coverage Act of 2017” (CCCA), legislation that would provide access to cost-free contraception for women and expand coverage to men to ensure the continuation of contraception coverage under state law in light of Republicans’ goal of repealing the ACA.  The CCCA would (1) statutorily require state-governed health insurance policies to provide cost-free coverage for all FDA-approved methods of birth control, including emergency contraception, (2) prohibit insurance companies from “medical management” review restrictions that can limit or delay contraceptive coverage; (3) cover men’s contraceptive methods and bring their insurance coverage in line with the benefits enjoyed by women; and (4) allow for the provision of a year’s worth of a contraceptive at a time.

Crain’s New York Business addressed a number of items that are at stake in terms of women’s access to health care in New York under Donald Trump’s presidency. Although New York’s contraception legislation “has taken on new urgency for advocates since Trump’s victory,” the bill faces opposition from insurers because the provisions go beyond the ACA mandates, Crain’s predicted. In addition, Crain’s pointed out that Republicans in Congress will renew their efforts to defund Planned Parenthood, noting that access to services such as breast exams, Pap tests, STD screenings and family planning are most likely at risk of elimination for female Medicaid enrollees. Finally, abortion rights in New York might be curtailed if President-elect Trump’s Supreme Court judge appointee provides the Court with a majority of votes to overturn Roe v. Wade, the case that affirmed a woman’s constitutional right to an abortion under the 14th amendment. New York state law allows an abortion after 24 weeks only if it’s a matter of life and death for the woman, while constitutional law allows a woman to get a late-stage abortion if an anomaly poses a serious risk to her health or makes the fetus unviable, Crain’s explained.

Other States

In 2014, California passed the Contraceptive Coverage Equity Act of 2014 that requires plans to cover prescribed FDA-approved contraceptives for women without cost-sharing. In April of 2016, under the law, girls and women are able to drop by their neighborhood pharmacy and pick up birth control such as pills, patches, and injections without a doctor’s prescription but must speak with a pharmacist and fill out a questionnaire. Starting in January 2016, health plans were required to provide access to the full range of contraceptive methods approved by the FDA, including a variety of IUDs, for all insured individuals without cost-sharing, delays, or denial of coverage.

In 2015, Oregon passed two laws in 2015  expanding women’s access to birth control that became effective January 1, 2015.  HR2879 permits pharmacists to prescribe hormonal contraceptive patches and self-administered oral hormonal contraceptives, while HR3343 requires insurers to pay for a three-month supply of contraceptives when first prescribed, followed by a 12 month supply of contraceptives regardless of whether the woman was insured by the same plan at the time of the first dispensing. This law applies to oral contraceptive pills, the patch, and the vaginal ring.

The State Journal Register reported that Illinois adopted House Bill 5576, which will take effect January 1, 2017. Under the law, all ACA options must be covered without co-payments or deductibles, at least for women covered through health plans regulated by the state and plans that cover state employees, retirees, and their dependents. In addition, insurance companies must allow women to get a 12 month supply all at once.

The Burlington Free Press reported that Vermont legislation includes mandates from the ACA in the state law, but also expands upon the mandates to include additional birth-control methods, such as vasectomies. The bill specifies the 12 contraceptive products and services that must be included in health insurance plans as well as restrictions on cost-sharing for contraceptive services. It directs the Department of Vermont Health Access to establish 15 value-based payments for the insertion and removal of long-acting reversible contraceptives comparable to those for oral contraceptives.

Conclusion

Whether Congress repeals the ACA mandates requiring health insurance plans to provide contraceptive coverage and defunds Planned Parenthood is not certain. As of this writing, Congress has already taken initial steps to repeal the law. It remains to be seen if the actions the states have taken to ensure that both men and women have access to contraception under state law will hold up, and whether states that have introduced bills to ensure coverage will progress to enactment in the face of strong opposition.

 

Zika’s potential impact on abortion legislation in Latin America

The Zika virus has been a hot topic in the news, with reactions varying from panic to dismissal. The biggest concern surrounding the disease is the potential for severe birth defects in children born to women who were infected while pregnant, which has stirred up the always-controversial topics of reproductive rights and decisions.

Virus

Like dengue and chikungunya, Zika is spread through mosquito bites. The virus symptoms themselves are surprisingly mild. The Centers for Disease Control and Prevention (CDC) reports that common symptoms are fever, rash, joint pain, and red eyes lasting up to a week. Only about one in five people who are infected with the virus actually develop Zika, and those that do are simply encouraged to get rest, take acetaminophen, and drink fluids.

Where is it?

Zika outbreaks were noted in Africa, Southeast Asia, and the Pacific Islands prior to 2015. The virus was first identified in Brazil in May 2015, and has been reported in many other South American countries. Although no locally transmitted cases have been noted in the U.S., it has been brought into the country by those infected elsewhere. Local cases in Puerto Rico, the Virgin Island, and American Samoa have been detected.

The particular species of mosquito known to carry Zika, Aedes aegypti, is not as prevalent in the U.S. as more southern countries because it prefers tropical and sub-tropical climates. However, some studies have found that the Aedes is common in Louisiana, Florida, some areas of Texas, and is sometimes seen as far north as New York in the summer.

Pregnancy

The major discussion surrounding Zika has stemmed from reports of a serious birth defect and “other poor pregnancy outcomes” in babies born to mothers who were infected while pregnant. Microcephaly, a condition in which a baby’s head size is significantly reduced, has been linked to the virus. According to the Mayo Clinic, microcephaly usually causes the brain to develop abnormally or fail to grow as expected, often causing developmental delays. As a result of these concerns, the CDC and other agencies recommend that women who are pregnant avoid traveling to areas where Zika is known. The first confirmed pregnancy case in Europe was recently found in Spain, where a woman recently returned from Colombia.

Controversy

The talk of Zika and potential serious birth defects has brought up a discussion regarding abortion laws, especially in heavily religious countries like Brazil where abortion is illegal in most cases. According to the New York Times, a case is already being prepared to fight for pregnant women to have the option for an abortion when microcephaly is discovered, and a judge has already expressed support for that side of the issue. Other groups are speaking up about keeping the restrictions as they currently are, or making abortions still harder to obtain. Some are recalling the legal battles in the U.S. surrounding abortions when it was discovered that contracting rubella during pregnancy would result in “damaged children”—an article published in the Wall Street Journal in 1966 sounds eerily similar to the discussion today. The Therapeutic Abortion Act, enacted during the rubella scares before a vaccine was developed, made California the first state to legalize abortion, with restrictions.

Those pushing for easier access to abortions note that contraception is particularly hard to obtain in Latin America. In addition, the culture often allows men to call the shots on how large a family becomes. Even though El Salvador’s government advised women to postpone pregnancy for two years, those studying family planning in the reason state that such actions are simply not feasible for many women—especially considering that clinics in five countries in the region exhausted their contraceptive supplies in 2015. Maternity and labor and delivery care are also hard to come by especially for the poor, resulting in many women giving birth outside of a medical facility. Sources have reported that millions of women have sought unsafe abortions in the region, often resulting in further health issues.

CMS clarifies user fee adjustment mechanism for contraception accommodation

Third-party administrators (TPAs) must submit the Notice of Intent Disclosure Form to CMS stating their intention to seek a user fee adjustment even though the original deadline has passed. CMS has issued answers to frequently asked questions for TPAs, pharmacy benefit managers (PBMs), and federally-facilitated marketplace (FFM) issuers who are seeking reimbursement for contraceptive services. The information that these parties must submit will allow CMS to determine the discount to be applied to the user fee paid for participation on the FFM (CMS FAQ, November 9, 2015).

User fee discount

The government has provided an accommodation for self-insured nonprofit religious organizations that object to the contraceptive coverage mandate found in sections 1001 and 1004 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). Under the accommodation, the nonprofit or their TPA notifies HHS of the objection. The TPA will cover the contraceptive services and will contract with an FFM issuer. The FFM reduces the issuer’s marketplace user fee to account for the payment made to the TPA to cover the services. In order to receive this discount, FFM issuers and TPAs must submit certain information to CMS.

FAQs

TPAs and PBMs must submit the notice of intent form by November 13, 2015, via email. FFM issuers seeking the 2014 benefit year adjustment should submit their spreadsheets by December 11, 2015. CMS will provide webinar training on completing the forms. The document contains instructions regarding recipient email address, subject lines, and attachments.

CMS clarifies that PBMs can enter in the same arrangements as TPAs to provide contraceptive services. PBMs must follow the requirements imposed on TPAs. However, if the TPA or PBM and the FFM issuer are part of the same entity or parent company, only the FFM should submit its spreadsheet. If the entities are separate, the TPA must submit its form indicating the total value of eligible paid claims.

The user fee discount is limited to the dollar amount of contraceptive claims. CMS intends to deduct the appropriate amount from the issuer’s monthly obligation at the end of the 2015 calendar year. The FFM issuer is also eligible for an additional 15 percent payment for administrative costs. Although CMS has not established reimbursement for TPA or PBM administrative costs, these groups may require that the FFM share part of its administrative payment.